Why Psychiatrists Need to Screen for Eating Disorders

Drew Ramsey, MD; Deborah R. Glasofer, PhD


August 23, 2019

Editorial Collaboration

Medscape &

This transcript has been edited for clarity.

Drew Ramsey, MD: Hello from the 175th Annual American Psychiatric Association Conference. We're here filming for Medscape and Columbia Psychiatry. We wanted to give you an update on eating disorders.

I'm here with a good friend and colleague at Columbia Psychiatry who is a psychologist, researcher, and clinician: Deb Glasofer. She's been in our department for as long as I have. You are really my go-to expert when I'm struggling with one of my patients and trying to do a better job treating eating disorders.

I just wanted to start there, Deb. How can we do a better job in terms of screening in order to help patients with eating disorders?

Deborah R. Glasofer, PhD: First, thanks so much for having me and for asking me to answer some of these questions. I love helping psychiatrists learn more questions to ask their patients and how to better assess these kinds of problems.

I find, when people are coming to me for a specialized assessment, that some of the questions I ask that they haven't been asked before are things like, what kinds of rules they're following about their eating; what their general eating pattern is like; what their psychological experience around eating is; and do they feel guilty, ashamed, or out of control when or after they eat?

I often ask people a little bit about their weight history. I will ask, if they tell me that they've used certain drugs, whether they might be using those to impact their appetite—for example, stimulants that have been prescribed or something like cocaine, if their child has used that recreationally.

Ramsey: When you have a patient come in who's underweight and you're concerned, but it's not the topic of discussion, how do you get started?

Glasofer: When I'm concerned about weight? Well, it depends on what their presenting complaint is. I know that when people are generally undernourished, anxiety tends to go way up and mood tends to go way down.

Usually there is a way in with some symptom that is bringing them in the door, to connect that and ask if they've experienced any change in weight lately. Sometimes that's a way to get there.

Ramsey: I feel like I haven't updated my eating disorder knowledge since residency. Have there been changes or advances in terms of diagnosis or other things we should know about?

Glasofer: Sure. Binge eating disorder, which was considered a putative diagnosis in the appendix in DSM-4, has moved into the feeding and eating disorder section in DSM-5. It is well researched and well recognized.

There's also a diagnosis now called avoidant restrictive food intake disorder (ARFID, for short). A lot of research is being done to better understand who these individuals are. As defined in DSM-5, these are folks who are having a lot of difficulty nutritionally or weight-wise due to restrictive eating.

They might be restricting because of textures of food, colors of food, or a fear of nausea or vomiting. They're running into a functional impairment because of their restrictive eating. These folks do not have body image concern and they're not afraid of getting fat. They're quite motivated to gain weight, but they're very afraid of eating a wider array of foods that would help them to do so.

As I said, there's a lot of research going on right now to understand whether a broad diagnosis is sufficient or if we are actually talking about different groups of people who land here for different reasons.

Ramsey: Just shifting gears a little bit, many of us in clinical practice are getting so many questions about food and diet, and there are so many different types of diets and eating plans.

Are there certain ones that are red flags for you? Are there certain things that we should be screening in terms of how patients are engaging and different types of plans for their eating?

Glasofer: I learn the most about different diets from patients who come in and tell me a story that starts with a diet that they've come on. I don't know, in particular, a diet to flag.

I think, in general, it is important to understand that there should be flexibility to eating. Even if someone feels it's important to follow certain principles or guidelines in what they're eating, it should be really malleable.

This way, it isn't hard to grab a meal on the go even if you're at an airport that doesn't have food where you know where all of it is sourced. You should be able to eat dinner with your family, even if that means there's going to be something processed in the meal. That's the main thing that I'm helping people to think about. Rather than saying absolutely no to this and absolutely no to that, I'm focusing on the general principles of normal eating.

You're a vegetarian? Okay. Are you able to get all of the nutrients you need that way? Are you able to sustain a weight that is psychologically and physically healthy for your body? Great.

If not, if vegetarianism was a step on the way to eating an extremely restrictive diet, to losing weight, and to a very unhealthy physical and psychological state for you, well, maybe that's something that needs to be addressed as part of a treatment plan. It really depends on the individual and the type of eating problem they're experiencing.

Ramsey: Thank you for all of those updates. Something that you've helped me with, and I'd encourage all of you, is to simply remember to screen; and when we find eating disorders, refer to our colleagues who are specialists in that area to help us get our patients fully well.

Dr Glasofer, thank you for joining us. We'll see you next time, here on Medscape Psychiatry.

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